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LINDA W. PRINE, MD, Beth Israel Residency in Urban Family Medicine at the Institute for Family Health, New York, New York
HONOR MACNAUGHTON, MD, Tufts University Family Medicine Residency at Cambridge Health Alliance,
Malden, Massachusetts
The management of early pregnancy loss used to be based largely in the hospital setting, but it has shifted to the
outpatient setting, allowing women to remain under the care of their family physician throughout the miscarriage
process. Up to 15 percent of recognized pregnancies end in miscarriage, and as many as 80 percent of miscarriages
occur in the first trimester, with chromosomal abnormalities as the leading cause. In general, no interventions have
been proven to prevent miscarriage; occasionally women can modify their risk factors or receive treatment for relevant medical conditions. Unless products of conception are seen, the diagnosis of miscarriage is made with ultrasonography and, when ultrasonography is not available or is nondiagnostic, with measurement of beta subunit of
human chorionic gonadotropin levels. Management options for early pregnancy loss include expectant management,
medical management with misoprostol, and uterine aspiration. Expectant management is highly effective for the
treatment of incomplete abortion, whereas misoprostol and uterine aspiration are more effective for the management
of anembryonic gestation and embryonic demise. Misoprostol in a dose of 800 mcg administered vaginally is effective
and well-tolerated. Compared with dilation and curettage in the operating room, uterine aspiration is the preferred
procedure for early pregnancy loss; aspiration is equally safe, quicker to perform, more cost-effective, and amenable
to use in the primary care setting. All management options are equally safe; thus, patient preference should guide
treatment choice. (Am Fam Physician. 2011;84(1):75-82. Copyright 2011 American Academy of Family Physicians.)
Patient information:
A handout on miscarriage,
adapted from Reproductive Health Access Project,
is provided on page 85.
Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright 2011 American Academy of Family Physicians. For the private, noncommercial use of
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requests.Physician 75
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Evidence
rating
References
39, 40
46-52
47, 50
50, 51
54-56
C
B
57
59
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort.xml.
The risk of pregnancy loss in symptomatic and asymptomatic pregnancies drops once fetal cardiac activity has
been demonstrated on ultrasonography. In pregnant
women presenting with first-trimester bleeding, the presence of fetal cardiac activity decreases the likelihood of
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Definition
Ultrasound characteristics
Anembryonic
gestation
Complete abortion
Ectopic pregnancy
Embryonic or fetal
demise
Incomplete abortion
Inevitable abortion
Recurrent abortion
Septic abortion
Threatened abortion
Diagnosis
Early pregnancy loss is divided into subcategories that
are defined by a combination of clinical and ultrasound
findings1 (Table 3). Women experiencing a miscarriage
can present to their family physician in a number of
ways, including with vaginal bleeding, absent fetal heart
tones on Doppler, size-dates discrepancy on bimanual
examination, or a routine ultrasonography indicating a
nonviable pregnancy. Patients with vaginal bleeding that
is not self-limited should be assessed for signs and symptoms of hemodynamic instability, although this is rare.
A baseline complete blood count is warranted in most
cases. Physical examination should routinely include a
bimanual examination for size-dates discrepancy and
extrauterine tenderness or masses that may indicate
ectopic pregnancy or rupture. Speculum examination
can be diagnostic if the products of conception are visible in the cervical os or vaginal vault.
In the absence of visible tissue or an open cervical os,
miscarriage must be differentiated from a viable intrauterine pregnancy or ectopic pregnancy by ultrasonography, serial beta subunit of human chorionic gonadotropin
(-hCG) levels, or both.38-40 Transvaginal ultrasonography is the most reliable way to differentiate between viable
July 1, 2011
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Physical examination
Peritoneal signs
or hemodynamic
instability
Transfer to
emergency
department
Nonobstetric cause
of bleeding identified
Products of conception
visible on examination
Diagnose
and treat as
indicated
Incomplete
abortion, treat
as indicated
Ectopic pregnancy or
signs suggestive of
ectopic pregnancy
Presume ectopic
pregnancy; refer for
high-level TVUS*
and/or treatment
TVUS
Viable IUP
Nonviable IUP
Threatened abortion;
repeat TVUS if
further bleeding
Embryonic demise,
anembryonic gestation,
or retained products
of conception; discuss
treatment options
IUP, viability
uncertain
No IUP, no ectopic
pregnancy seen
No
Obtain -hCG
level immediately;
see Figure 2
Yes
Completed
abortion;
expectant
management
Figure 1. Algorithm for the evaluation of first-trimester bleeding. (-hCG = beta subunit of human chorionic gonadotropin; IUP = intrauterine pregnancy; TVUS = transvaginal ultrasonography.)
Adapted with permission from the Reproductive Health Access Project. First trimester bleeding algorithm. http://www.reproductiveaccess.org/m_m/
downloads/First_trimester_bleeding_algorithm.pdf. Accessed April 29, 2011.
that family physicians can perform first-trimester ultrasonography with equivalent skill to radiologists and
obstetricians.43-45 If ultrasonography is not immediately
available and the patient is stable, an urgent quantitative -hCG measurement can be done as the initial step
in the workup. The patient should be warned of the
symptoms of ectopic pregnancy that warrant a call to
the physician or a visit to the emergency department. If
the quantitative -hCG level is greater than the 1,500 to
2,000 mIU per mL discriminatory zone, an urgent ultrasonography should be arranged to rule out an ectopic
pregnancy and assess viability. If below the discriminatory zone, serial -hCG levels can be followed every 48
hours until the discriminatory threshold is reached or
until the diagnosis is clear from the trend of the -hCG
levels (Figure 242).
78 American Family Physician
Treatment
Three options exist for treating first-trimester miscarriage: expectant management, medical management
with misoprostol (Cytotec), and uterine aspiration. All of
these options are safe but have varying degrees of success
depending on the type of miscarriage, and the patient
should be informed of these data.46-50 Expectant management is highly effective for the treatment of incomplete
abortion, whereas misoprostol and uterine aspiration
are more effective for the management of anembryonic
gestation and embryonic demise.46-51 An effectiveness
comparison of expectant versus medical management of
various types of miscarriage is presented in Table 4.47,49
After being counseled on her options, the patient should
be allowed to select her treatment.52 Urgent aspiration
should be performed only if she is having brisk bleeding,
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July 1, 2011
Yes
No
Completed abortion;
expectant management
-hCG > 1,500 to 2,000 mIU per mL*
Repeat -hCG
decreased < 50
percent or increased
Repeat -hCG
decreased
> 50 percent
Repeat -hCG
decreased
> 50 percent
Repeat -hCG
increased > 66
percent
Suggests viable
pregnancy, but not
diagnostic; follow
-hCG until 1,500
to 2,000 mIU per
mL,* then TVUS for
definitive diagnosis
*The -hCG level at which an IUP should be seen on TVUS is referred to as the discriminatory zone, and varies between 1,500 and 2,000 mIU per
mL depending on the machine and the sonographer; knowledge of the discriminatory zone for a particular machine and sonographer is necessary
for appropriate triage of results in this range.
High-level TVUS entails a formal ultrasonography by radiology.
-hCG needs to be followed to zero only if ectopic pregnancy has not been reliably excluded; if a definitive diagnosis of completed miscarriage
has been made, there is no need to follow further -hCG levels.
Figure 2. Algorithm for the evaluation of first-trimester bleeding when no intrauterine pregnancy is seen on ultra
sonography. (-hCG = beta subunit of human chorionic gonadotropin; IUP = intrauterine pregnancy; TVUS = transvaginal ultrasonography.)
Adapted with permission from the Reproductive Health Access Project. First trimester bleeding algorithm. http://www.reproductiveaccess.org/m_m/
downloads/First_trimester_bleeding_algorithm.pdf. Accessed April 29, 2011.
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By day
7*
By day
14*
By day
46*
Completed miscarriage
after taking misoprostol
(Cytotec) by day 8* (%)
Incomplete abortion
Embryonic demise
Anembryonic
gestation
All categories
53
30
25
84
59
52
91
76
66
93
88
81
40
70
81
84
MEDICAL MANAGEMENT
Numerous studies have shown misoprostol, a prostaglandin analogue, to be a safe and effective treatment
for early pregnancy loss.48-51 One evidence-based protocol includes 800 mcg of misoprostol vaginally with
a repeat dose in 48 hours, if needed.49 Studies comparing a variety of doses and routes of administration have
found that lower doses and oral administration are
less effective, and sublingual administration is associated with greater adverse effects.51 Ongoing studies
continue to search for the optimal doses and routes of
administration.53
When women choose medical management, the
miscarriage process usually evolves more quickly and
predictably than with expectant management.50,51
Cramping and bleeding typically occur within two to
six hours of misoprostol insertion, with the most severe
symptoms resolving in about three to five hours. Pretreatment with a nonsteroidal anti-inflammatory drug
before administering the misoprostol is helpful to block
the adverse effects of fever, chills, and severe cramping,
and a combination narcotic/acetaminophen should also
be prescribed. As with expectant management, a followup appointment is important to document completion.
A take-home instruction sheet for patients using misoprostol is available at http://www.reproductiveaccess.
org/m_m/MiscarriageUsingMeds.htm.
UTERINE ASPIRATION
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The authors thank Marji Gold, MD; Ruth Lesnewski, MD; Rebecca
Simons, MD; and Finn Schubert for their assistance in the preparation of
the manuscript.
July 1, 2011
The Authors
LINDA W. PRINE, MD, is a faculty member at the Beth Israel Residency in
Urban Family Medicine at the Institute for Family Health, New York, NY,
and an associate clinical professor at Albert Einstein College of Medicine
of Yeshiva University, Bronx, NY.
HONOR MACNAUGHTON, MD, is a faculty member at Tufts University
Family Medicine Residency at Cambridge Health Alliance, Malden, Mass.,
and an assistant clinical professor in the Department of Family Medicine
at Tufts University School of Medicine, Boston, Mass.
Address correspondence to Linda W. Prine, MD, Beth Israel Residency
in Urban Family Medicine at the Institute for Family Health, 16 East 16th
St., New York, NY 10003 (e-mail: lindaprine@mac.com). Reprints are
not available from the authors.
Author disclosure: No relevant financial affiliations to disclose.
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